Wiki Coding "Probable" diagnosis

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elizabethyoung

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Hi

My ER doctors are informing me that I should be coding charts if they use the word "Probale" as their "Main diagnosis". From my knowledge of the "AMA" guidelines words that began with ruleout, probable, susupected, and questionable cannot be coded. Can someone tell me if this is still a general rule?

Thanks,

:confused:
 
Outpatient coders should not code "possible", "probable", "suspected", "question of". We should choose a diagnosis from symptoms instead.
 
When coding for provider services (whether inpatient or outpatient), you are to use the coding instructions that appear in Section IV of the Official ICD-9 Guidelines for Coding and Reporting that appears at the beginning of your ICD-9 book.

This section says:

I. Uncertain diagnosis

Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.
 
Coding Inpatient Uncertain Diagnoses

I'd like to update this thread. The 2012 ICD-9-CM Guidelines for Coding and Reporting, Section II. Selection of Principal Diagnosis, H. Uncertain Diagnosis, which governs inpatient care, states:

If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note: The guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.
 
KimberlySherman said:
I'd like to update this thread. The 2012 ICD-9-CM Guidelines for Coding and Reporting, Section II. Selection of Principal Diagnosis, H. Uncertain Diagnosis, which governs inpatient care, states:

If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note: The guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.
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That guideline is and always has been for inpatient facility use not for physician codeing or hospital outpatient. Just to clarify.
 
I am getting this guideline from my 2012 Ingenix ICD-9 Physician coding book. It is under the "Official ICD-9 Guidelines for Coding and Reporting". Section II. Selection of Principal Diagnosis, introduction, states that "In determining principal diagnosis the coding conventions in the ICD-9-CM, Volumes I and II take precedence over these [UHDDS] official coding guidelines." It then goes on to enumerate what these guidelines are, which includes Section II.H. Uncertain Diagnoses.
 
mitchellde said:
That guideline is and always has been for inpatient facility use not for physician codeing or hospital outpatient. Just to clarify.
Click to expand...

Hi Debra,

Just to make certain, so if our physicians are seeing patients in the inpatient setting and are not employed by the hospital, they CANNOT code off of probable, rule out, uncertain diagnosis?

Whether facility coding (hospital) or physician billing, can a "resolved" diagnosis be billed? If it can under which scenario would that fall under?

Thank you,
 
Physician coding may never code a possible diagnosis, they may code only confirmed diagnosis or signs and symptoms. As far as a resolved dx then it will depend on what it is. If the patient is returning for an infection and it is documented as resolved at this encounter then we code the infection since that is why the patient is returning and it not deemed resolved until after exam. However for other conditions such as post surgical we code a follow up code from the V67.xx category or an aftercare code such as a V54.x or V58.xx.
 
mitchellde said:
Physician coding may never code a possible diagnosis, they may code only confirmed diagnosis or signs and symptoms. As far as a resolved dx then it will depend on what it is. If the patient is returning for an infection and it is documented as resolved at this encounter then we code the infection since that is why the patient is returning and it not deemed resolved until after exam. However for other conditions such as post surgical we code a follow up code from the V67.xx category or an aftercare code such as a V54.x or V58.xx.
Click to expand...

Thank you Debra so much for your reply..

Facility coding: Can bill probable, rule out, etc.
Physician coding, non-facility: Cannot bill probable, rule out, etc. code off of signs and symptoms.

Resolved: unless continuing care, cannot bill for resolved in either the facility inpatient coding or physician coding, non facililty.

I though just to summarize it.. ;)
 
Need reassurance...

dscoder74 said:
Thank you Debra so much for your reply..

Facility coding: Can bill probable, rule out, etc.
Physician coding, non-facility: Cannot bill probable, rule out, etc. code off of signs and symptoms.

Resolved: unless continuing care, cannot bill for resolved in either the facility inpatient coding or physician coding, non facililty.

I though just to summarize it.. ;)
Click to expand...

What I have stated is this accurate? I would like to hear others' opinions.

Thank you,
 
On the surface it looks good, just remember specific documentation can always assist with answering a question. The facility rule is for inpatient coders only. Outpatient follows physician rules.
 
mitchellde said:
On the surface it looks good, just remember specific documentation can always assist with answering a question. The facility rule is for inpatient coders only. Outpatient follows physician rules.
Click to expand...

Thanks Debra for responding again. I have been in the coding industry since 1995, the past two years I have been auditing physician hospital coding and documentation. I did not have any formal education on this so it's been a hit and miss learning about the rules. Unfortunately physicians at times can get confused on which rules apply to them. Thanks again for the reassurance...
 
mitchellde said:
Physician coding may never code a possible diagnosis, they may code only confirmed diagnosis or signs and symptoms. As far as a resolved dx then it will depend on what it is. If the patient is returning for an infection and it is documented as resolved at this encounter then we code the infection since that is why the patient is returning and it not deemed resolved until after exam. However for other conditions such as post surgical we code a follow up code from the V67.xx category or an aftercare code such as a V54.x or V58.xx.
Click to expand...

"If the patient is returning for an infection and it is documented as resolved at this encounter then we code the infection since that is why the patient is returning and it not deemed resolved until after exam."

What happens then when after the exam, the patient has no indication of an infection, do you still bill it? If the physician states in his exam that there is no indication of infection, can he still bill it?

Thank you,
 
yes we are coding the reason for the visit which was the infection, if the patient is instructed to return yet again just to be sure then that visit gets a V67.x code for follow up following completed therapy. There is an old coding clinic on this which is where I learned, but I do not remember the year, sorry.
 
mitchellde said:
yes we are coding the reason for the visit which was the infection, if the patient is instructed to return yet again just to be sure then that visit gets a V67.x code for follow up following completed therapy. There is an old coding clinic on this which is where I learned, but I do not remember the year, sorry.
Click to expand...

Hi Debra,

Thanks for the reply. I code and audit in Nephrology/Internal medicine. So let's say that the patient had acute renal failure on the previous visit and the patient comes back, the physician documents that the patients' acute renal failure has resolved, can he still bill for it?

If the patient had hyperkalemia (elevated potassium reading) on the previous visit, the patient comes back and the labs prove that the patient no longer has it, the physician states in his documentation that the hyperkalemia has resolved. Can he bill for hyperkalemia?

I need to know if this applies to the outpatient rules? Office and Non-facility (hospital) physician coding.

I truely appreciate your feedback.

Thank you,
 
Coding Clinic 2000 3Q

When coding for physician services, whether provided in the hospital inpatient setting or in the physician office, coders should be guided by the Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office). The inpatient guidelines are for hospital coding. Therefore, in the outpatient settings do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis." Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. V-codes may be assigned when appropriate. Please refer to the V-code article published in Coding Clinic, Fourth Quarter 1996 and Fourth Quarter 1998, respectively, for further discussion.
 
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